Challenger in Laparoscopy

D

ear Colleagues, It is a great pleasure to invite you to Leipzig for the 8th European Meeting of “Challenges in Laparoscopy and Robotics”.

The scientific program will include live laparoscopic and robotic surgery performed by the world’s most renowned surgeons. Interesting presentations and pertinent debates to laparoscopy and robotics will enrich the program and guarantee a scientific program at the highest level.

Leipzig is an historical city with a rich cultural and commercial profile.

Major classical music composers have lived and flourished here.

In addition, major car industries (Porsche and BMW) are producing several of their lines in Leipzig.

Clearly, music, action and speed are the major characteristics of this city. This is the perfect city to host “Challenges in Laparoscopy and Robotics”. We hope that you will follow the sound, action and speed of this special program and that this will be a memorable meeting for all of you from a scientific as well as a social standpoint.

Welcome to Leipzig!

Vincenzo Disanto Evangelos Liatsikos Vito Pansadoro Jens-Uwe Stolzenburg

General Program

Course Directors, Scientific Committee and Local Organizing Committee, Invited Surgeons, Invited Speakers & Moderators

Course Directors

Course Directors

Vincenzo Disanto, MD Policlinico Abano Terme Abano, Italy

Evangelos Liatsikos, MD University of Patras Patras, Greece

Vito Pansadoro, MD Vincenzo Pansadoro Foundation Rome, Italy

Jens Uwe Stolzenburg, MD University of Leipzig Leipzig, Germany

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Scientific Committee

Local Organizing Committee

Vincenzo Disanto, MD Policlinico Abano Terme Abano, Italy

Amir Hamza, MD St. Georg Hospital Leipzig, Germany

Richard Gaston, MD Clinique Saint Augustin Bordeaux, France

Evangelos Liatsikos, MD University of Patras Patras, Greece

Inderbir Gill, MD, MCH Keck School of Medicine, University of Southern California Los Angeles, USA

Jörg Rassler, MD St. Elisabeth Hospital Leipzig, Germany

Günter Janetschek, MD Medical University Salzburg Salzburg, Austria

Jens Uwe Stolzenburg, MD University of Leipzig Leipzig, Germany Holger Till, MD University of Leipzig Leipzig, Germany

Evangelos Liatsikos, MD University of Patras Patras, Greece Alex Mottrie, MD O.L.V.-Clinic Aalst, Belgium Vito Pansadoro, MD Vincenzo Pansadoro Foundation Rome, Italy Thierry Pièchaud, MD Clinique Saint Augustin Bordeaux, France Jens Rassweiler, MD SLK Kliniken Heilbronn University of Heidelberg, Germany Jens Uwe Stolzenburg, MD University of Leipzig Leipzig, Germany Roland Van Velthoven, MD Service InterHospitalier d'Urologie Brussels, Belgium

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Committees

Scientific Committee and Local Organizing Committee

Notes

Renaud Bollens, MD Professor and Chairman G.H.I.C.L (Groupe Hospitalier de l’institut Catholique de Lille) Lille, France

Inderbir S. Gill, MD, MCH Chairman and Donald G. Skinner Professor Department of Urology Executive Director, USC Institute of Urology Associate Dean (Clinical Innovation) Keck School of Medicine, University of Southern California Los Angeles, USA

Alberto Breda, MD Director Transplant Unit Fondation Puigvert Barcelona, Spain

GĂźnter Janetschek, MD Professor and Chairman Department of Urology Medical University Salzburg Salzburg, Austria

Vincenzo Disanto, MD Director, Laparoscopy Center Policlinico Abano Terme Abano, Italy

Jihad H. Kaouk, MD Zegarac-Pollock Professor of Surgery Institute Vice Chair for Surgical Innovations Director, Center for Laparoscopic and Robotic Surgery Glickman Urological and Kidney Institute Cleveland Clinic Cleveland, USA

Richard Gaston, MD Center of Urologic Laparoscopy Department of Urology Clinique Saint Augustin Bordeaux, France

Evangelos Liatsikos, MD Assistant Professor Department of Urology University of Patras Patras, Greece

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Invited Surgeons

Invited Surgeons

Invited Surgeons

Alex Mottrie, MD Department of Urology O.L.V.-Clinic Aalst, Belgium

JĂśrg Rassler, MD Chairman Department of Gynecology St. Elisabeth Hospital Leipzig, Germany

Vito Pansadoro, MD Director, Laparoscopy Center Vincenzo Pansadoro Foundation Rome, Italy

Jens Rassweiler, MD Head of Department of Urology SLK Kliniken Heilbronn University of Heidelberg, Germany

Vipul Patel, MD Medical Director of Urologic Oncology, Florida Hospital Medical Director of Global Robotics Institute Associate Prof of Urology University of Central Florida Florida, USA

Peter Rimington, MD Director of Urology Eastbourne District General Hospital Eastbourne, UK

Thierry Pièchaud, MD Center of Urologic Laparoscopy Clinique Saint Augustin Bordeaux, France Chairman of Urologic Courses IRCAD-EITS, Strasbourg, France

Jens Uwe Stolzenburg, MD, FRCS (Ed) Professor and Chairman Department of Urology Head of International Training Center of Urologic Laparoscopy University of Leipzig Leipzig, Germany

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Invited Surgeons

Xu Zhang, MD, PhD

Holger Till, MD Director, Department of Pediatric Surgery University of Leipzig Leipzig, Germany

Professor and Chairman Chinese PLA General Hospital Beijing, China

Ingolf Tßrk, MD, PhD Chief of Urology Director Robotic Assisted Surgery Program St. Elizabeth’s Medical Center Professor for Urology Tufts School of Medicine Boston, USA

Roland Van Velthoven, MD Chairman Department of Urology Service InterHospitalier d'Urologie Institut Jules Bordet Hospital Saint Pierre Brussels, Belgium

Peter Wiklund, MD Professor and Chairman Dept. of Molecular Medicine and Surgery, Section of Urology, Karolinska Institut Stockholm, Sweden

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Invited Surgeons

Department of Urology

Invited Speakers & Moderators

Chris Anderson, MD Consultant Urological Surgeon and Lead Cancer Clinician Deptartment of Urology St George’s University Hospital London, UK

Guglielmo Breda, MD

Walter Artibani, MD

Francesco Curto, MD

Professor and Chairman

Department of Urology, A.R.N.A.S.

Department of Urology

Civic Hospital Palermo

University of Padua, Italy

Palermo, Italy

Alexander Bachmann, MD Chairman Department of Urology University Hospital Basel Basel, Switzerland

Gianluca D’Elia, MD

Professor and Chairman Department of Urology San Bassiano Hospital Bassano del Grappa, Italy

Professor and Chairman Department of Urology San Giovanni Hospital Rome, Italy

Harrie Beerlage, MD Department of Urology Jeroen Bosch Hospital Hertogenbosch, The Netherlands

Michael Dunzinger, MD Head of the Department of Urology and Andrology Hospital Voecklabruck Head of the Board of Laparoscopy of the Austrian Urological Society Vöcklabruck, Austria

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Paolo Emiliozzi, MD Department of Urology San Giovanni Hospital Rome, Italy

Amir Hamza, MD Chairman Department of Urology St. Georg Hospital Leipzig Leipzig, Germany

Tibet Erdogru, MD Head Department of Urology Minimally Invasive & Robotic Surgery Center Memorial Atasehir Hospital Istanbul, Turkey

Panagiotis Kallidonis, MD Department of Urology University of Rio- Patras Patras, Greece

Franco Gaboardi, MD Professor and Chairman Department of Urology Sacco Hospital Milan, Italy

Konstantinos Konstantinidis, MD Professor and Chairman Department of Urology University of Athens Medical School Laikon General Hospital Athens, Greece

Giorgio Guazzoni, MD Professor and Chairman Department of Urology Università Vita e Salute “Ville Turro” San Raffaele Hospital Milan, Italy

Alan McNeill, MD Consultant Urological Surgeon and Honorary Senior Lecturer Department of Urology Lothian University Hospitals Edinburgh, Scotland

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Invited Speakers & Moderators

Invited Speakers & Moderators

Invited Speakers & Moderators

B端lent Oktay, MD Head Department of Urology Uludag University Faculty of Medicine Bursa, Turkey

Bernardo Rocco, MD Vice Director of Urologic Division European Insitute of Oncology Milan, Italy

Alberto Pansadoro, MD Department of Urology Civic Hospital Terni Terni, Italy

Constantinos Stravodimos, MD Assistant Professor of Urology Department of Urology University of Athens Medical School Laikon General Hospital Athens, Greece

Francesco Porpiglia, MD Associate Professor Department of Urology A.S.O. San Luigi Orbassano-Torino, Italy

Tullio Sulser, MD Professor and Chairman Clinic of Urology University Hospital Zurich Zurich, Switzerland

Abhay Rane, MD East Surrey Hospital Canada Avenue Redhill, UK

Peter Tenke, MD Jahn Ferenc South- Pest Teaching Hospital Budapest, Hungary

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Invited Speakers & Moderators

Joachim Thüroff, MD Professor and Chairman Department of Urology University of Mainz Mainz, Germany

Invited Speakers & Moderators

Michael Truß, MD Professor and Chairman Department of Urology Klinikum Dortmund Dortmund, Germany

Manfred Wirth, MD Professor and Chairman Department of Urology Universitätsklinikum “Carl Gustav Carus” der Technischen Universität Dresden Dresden, Germany

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Notes

Congress Program

Wednesday June 8th, Thursday June 9th, Friday June 10th, Saturday June 11th, 2011

Congress Program

Congress Program

Notes

Wednesday Wednesday, June 8th 2011

LAPAROSCOPY BEGINNERS COURSE

Coordinators of the Meeting

Presentations and dry lab training Storz Training Center Evangelos Liatsikos, Francesco Curto, Alberto Pansadoro - Specialized surgical instruments, devices and equipment - Set up of operating room and patient position - Indications and contraindications to laparoscopy - Transperitoneal and extraperitoneal access - Advantages and disadvantages of different access - Trocars’ position (several surgical procedures) - Knot tying, Suturing and Haemostasis - Anatomical landmarks for upper urinary tract - Anatomical landmarks for lower urinary tract - Surgical technique for: adrenalectomy/radical nephrectomy nephroureterectomy pieloplasty/nephropexy - Surgical technique for colpopexy/psoas hitch/ureteral, reimplantation/varicocelectomy - Management of complications

Hands on Training

- Pelvic Trainer - P.O.P. (Pulsating Organ Perfusion) Training - Live Training

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Congress Program

1:00 6:00 pm

Thursday Thursday, June 9th 2011

8:00 am Jens Uwe Stolzenburg Joachim Thüroff Walter Artibani Jens Rassweiler Evangelos Liatsikos Vincenzo Disanto Vito Pansadoro

Welcome Course director President SIU - Société Internationale d’Urologie Vice Secretary of the EAU Chairman ESUT Course director Course director President SIU - Società Italiana di Urologia

8:15 8:30 am Joachim Thüroff

SIU Lecture European Experience on open and minimally invasive partial nephrectomy

8:30 am 4:00 pm

Surgical Session UPPER TRACT Guglielmo Breda, Peter Tenke, Michael Truß, Amir Hamza, Bülent Oktay Robotic Donor Nephrectomy Provoker — Guglielmo Breda Hybrid Nephrectomy Provoker — Francesco Porpiglia Laparoscopic Radical Advanced Nephrectomy Provoker — Alan McNeill Single Port Robotic Nephrectomy Provoker — Franco Gaboardi Retroperitoneal Partial Nephrectomy Provoker — Roland Van Velthoven Clampless Partial Robotic Nephrectomy Provoker — Chris Anderson SMART Pyeloplasty with ETHOS-chair Provoker — Giorgio Guazzoni Ureteral Stricture repair Provoker — Joachim Thüroff Robotic Partial Nephrectomy Provoker — Tullio Sulser

Moderators Alberto Breda Evangelos Liatsikos Renaud Bollens Jihad Kaouk Vincenzo Disanto Inderbir Gill Jens Rassweiler Vito Pansadoro Alex Mottrie

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Thursday Thursday, June 9th 2011

Inderbir Gill Chris Anderson Evangelos Liatsikos 4:40 5:20 pm Moderators

Holger Till Harrie Beerlage Jens Rassweiler 5:20 6:00 pm Moderators

Debates Vito Pansadoro, Constantinos Stravodimos Nephrectomy and Partial Nephrectomy Standard Laparoscopy vs. Robot Assisted Laparoscopy vs. LESS Speaker Lap Speaker Robot Speaker LESS/ Needlescopic

Abhay Rane, Francesco Porpiglia Pyeloplasty Standard Laparoscopy vs. Robot Assisted Laparoscopy vs. LESS Speaker Lap Speaker Robot Speaker LESS/ Needlescopic

Alan McNeill Giorgio Guazzoni Jihad Kaouk

Alex Bachmann, Francesco Curto Nightmares of laparoscopic/robot assisted upper tract surgery – What you should never do. Standard Laparoscopy vs. Robot Assisted Laparoscopy vs. LESS Speaker Lap Speaker Robot Speaker LESS/ Needlescopic

6:00 pm

Adjournment

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Congress Program

4:00 4:40 pm Moderators

Friday

Friday, June 10th 2011

8:15 8:30 am Roland van Velthoven

ESUT Lecture European Experience on Laparoscopic Radical Cystectomy

8:30 am 4:00 pm

Surgical Session PELVIS Alberto Pansadoro, Alan McNeill, Michael Dunzinger, Tullio Sulser Robotic Cystectomy Provoker — Inderbir Gill Robotic extended Lymphadenectomy Provoker — Bernardo Rocco Robotic Neobladder Provoker — Alex Mottrie Laparoscopic Cystectomy Provoker — Walter Artibani Extended Laparoscopic Lymphadenectomy Provoker — Paolo Emiliozzi Laparoscopic Intracorporeal Bricker Provoker — Gianluca D’Elia Pediatric Pyeloplasty Provoker — Francesco Porpiglia Laparoscopic Burch Provoker — Joachim Thüroff Inguinal hernia repair Provoker — Alberto Pansadoro

Moderators Richard Gaston Inderbir Gill Peter Wiklund Peter Rimington Roland van Velthoven Richard Gaston Holger Till Jörg Rassler Jens-Uwe Stolzenburg

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Friday

Friday, June 10th 2011

Peter Rimington Peter Wiklund Joachim Thüroff 4:40 5:20 pm Moderators

Roland Van Velthoven Vipul Patel Manfred Wirth 5:20 6:00 pm Moderators

Debates Walter Artibani, Konstantinos Konstantinidis Cystectomy Standard Laparoscopy vs. Robot Assisted Laparoscopy vs. Open Speaker Lap Speaker Robot Speaker Open

Joachim Thüroff, Tullio Sulser Modifications of Radical Prostatectomy Evidence based data or surgeon’s wisdom Speaker Lap Speaker Robot Speaker Open

Thierry Pièchaud Jens Rassweiler Michael Truß

Ingolf Türk, Panagiotis Kallidonis General management of complications during Radical Prostatectomy Vascular injuries Rectal injury Anastomotic leakage

6:00 pm

Adjournment

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Congress Program

4:00 4:40 pm Moderators

Saturday Saturday, June 11th 2011

8:15 8:30 am Walter Artibani

EAU Lecture Robotics: Just the start of a new era in surgery

8:30 am 3:00 pm

Surgical Session PROSTATE DAY Harrie Beerlage, Tibet Erdogru, Amir Hamza, Abhay Rane, Thierry Pièchaud, Manfred Wirth Robotic Assisted Laparoscopic Prostatectomy Provoker — Ingolf Türk

Moderators

Vipul Patel Jens Uwe Stolzenburg

Endoscopic Extraperitoneal Radical Prostatectomy (with hernia repair) Provoker — Michael Truß

Ingolf Türk

Extraperitoneal Robotic Radical Prostatectomy Provoker — Franco Gaboardi

Richard Gaston

Laparoscopic Radical Prostatectomy (median lobe) Provoker — Chris Anderson Single Port Robotic Radical Prostatectomy Provoker — Evangelos Liatsikos Laparoscopic Radical Prostatectomy (with Fluorescence Staining) Provoker — Michael Dunzinger Laparoscopic Radical Prostatectomy (after TURP) Provoker — Tullio Sulser

Jihad Kaouk Günter Janetschek

Xu Zhang

3:00 pm

Adjournment

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Abstracts Thursday June 9th 2011

Abstracts Abstracts

Notes

Thursday Thursday, June 9th 2011

4:00 4:40 pm Moderators

Inderbir Gill Chris Anderson Evangelos Liatsikos 4:40 5:20 pm Moderators

Holger Till Harrie Beerlage Jens Rassweiler 5:20 6:00 pm Moderators

Debates Vito Pansadoro, Constantinos Stravodimos Nephrectomy and Partial Nephrectomy Standard Laparoscopy vs. Robot Assisted Laparoscopy vs. LESS Speaker Lap Speaker Robot Speaker LESS/ Needlescopic

Abhay Rane, Francesco Porpiglia Pyeloplasty Standard Laparoscopy vs. Robot Assisted Laparoscopy vs. LESS Speaker Lap Speaker Robot Speaker LESS/ Needlescopic

Alan McNeill Giorgio Guazzoni Jihad Kaouk

Alex Bachmann, Francesco Curto Nightmares of laparoscopic/robot assisted upper tract surgery – What you should never do. Standard Laparoscopy vs. Robot Assisted Laparoscopy vs. LESS Speaker Lap Speaker Robot Speaker LESS/ Needlescopic

6:00 pm

Adjournment

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Thursday Thursday, June 9th 2011

Laparoscopic Nephrectomy and Partial Nephrectomy Inderbir S. Gill Chairman and Donald G. Skinner Professor Department of Urology Executive Director, USC Institute of Urology Associate Dean (Clinical Innovation) Keck School of Medicine, University of Southern California Los Angeles, USA

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Thursday Thursday, June 9th 2011

Robotic Nephrectomy and Partial Nephrectomy: is robotic technology facilitating minimally invasive renal surgery Chris Anderson Consultant Urological Surgeon and Lead Cancer Clinician Deptartment of Urology St Georgeâ&#x20AC;&#x2122;s University Hospital London, UK Up to 50% of all renal tumors diagnosed today are <4cm in diameter, and they are usually detected in asymptomatic and frequently old and infirm patients. About 20% of these small renal tumors (SRT) are actually benign and the majority have a low potential to progress. As a result less invasive energy ablative and even active surveillance strategies are becoming increasingly more popular.. ~ 10% of SRTs have morphologic parameters suggesting higher aggressiveness, and this increases to ~30% in tumors 3-4cm in diameter. Imaging can not identify these more dangerous SRT s . If a therapeutic decision other than standard surgical removal is taken it should therefore be based on a biopsy . In our experience a CT guided core needle biopsy performed in local anesthesia as a separate procedure ( no frozen sections) provides adequate specimens in 97.5% of patients. It has a 95.2.% sensitivity, 100 % specificity , 100% positive predictive value and 81.3% negative predictive value for the diagnosis of malignant vs. benign tissue. Histologic subtype and Fuhrman grade can be correctly identified in 91% and 76% respectively. In contrast fine needle aspiration biopsies under similar conditions provided insufficient material in 11% of biopsies, and sensitivity and negative predictive value were only 90.6% and 70%, respectively. In 118 biopsies complications were observed in 4% of patients. They were always minor and most commonly formation of hematomas, and never needed further intervention.

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Abstracts Thursday June 9th 2011

Remzi,M , Marberger,M: Eur.Urol.2009:55,359-367 Schmidbauer et al.: Eur.Urol.2008:53,1003-12 Remzi et al: J.Urol. 2006:176,896-9

Thursday Thursday, June 9th 2011

LESS/ Needlescopic Nephrectomy and Partial Nephrectomy Evangelos Liatsikos Assistant Professor Department of Urology University of Patras Patras, Greece Laparoendoscopic single site surgery (LESS) nephrectomy is considered a technically challenging operation which limits the broader application of the technique. As every LESS operation, LESS nephrectomy is based on the concept that reducing abdominal ports, port related morbidity is diminished and a superior cosmetic result than multiport laparoscopy is provided. A nearly scareless outcome is evident in most of the cases, given that the single access is usually established and postoperatively hided within the umbilicus or other natural orifices (e.g vagina). Τhe advantages of LESS over conventional laparoscopy have not been clearly elucidated. Yet, worldwide experience with the technique is constantly expanding. In experienced laparoscopic centers, equivalent perioperative and oncological results to conventional laparoscopy have been documented for LESS radical, partial and donor nephrectomy. Additionally, expanding experience in single site surgery has provided tools such as transvaginal access, needlescopic instruments and robot assistance that can aid LESS nephrectomy and enhance its efficiency without compromising any of its advantages. A mix of these techniques with LESS could ease the stiff learning curve of the second and benefit not only its performance but the incorporation of LESS as a standard practice for nephrectomy in the near future as well.

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Thursday Thursday, June 9th 2011

Laparoscopic Pyeloplasty in children Holger Till Director, Department of Pediatric Surgery University of Leipzig Leipzig, Germany The PUJO (pelvi-ureteric junction obstruction) represents the most common cause for congenital hydronephrosis (Fefer 2006). The indication for a surgical correction is mainly based on renal function tests such as a MAG-III scintigraphy. In cases of severe obstruction the gold standard for an operation remains the Anderson-Hynes pyeloplasty, because it allows for success rates of up to 90% (Jarret 2004). Today, not the technique of pyeloplasty, but rather the access to the kidney remains a matter of vivid discussions. Since the first description of a laparoscopic pyeloplasty in adults by Schuessler in 1993, the minimal invasive approach has gained increasing popularity in children as well (Peters 1995). Meanwhile the transperitoneal and retroperitoneal access have been established in paediatrics (El-Ghoneimi 2003). Both have their pros and cons, especially when it comes to the reconstruction of the anastomosis in a very small space (Valla 2009). In any case the laparoscope allowed for magnified presentation of the PUJO and meticulous suturing.

The present literature presents many studies about the feasibility and the urological success rate of minimal invasive pyeloplasty (Ansari 2008; Szavay 2010), even in children younger than 1 year of age (Metzelder 2006).

Moreover, they convey distinct advantages for the patients like reduced postoperative pain, shorter length of hospital stay and improved cosmesis. Unfortunately, most of these studies in children were longitudinal, observational trials without control groups or randomization so that the level of evidence remained limited.

Additionally, in some reports the mean operating times seemed longer for the MIS group, while a few other were quite comparable (Cascio 2007).

Nowadays the minimal invasive pyeloplasty has achieved a high level of efficacy and safety in children and should be considered as the technique of choice in experienced hands.

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Abstracts Thursday June 9th 2011

In recent years robotic pyeloplasty has been advocated even in children. The protagonists pointed out that the robot allowed for a more subtle suturing (Chan 2010) and shorter operating time. Critics argued about higher costs and the size of the machine in contrast to 3mm standard laparoscopic instruments. With Laparo-endoscopic single-site surgery (LESS) entering the stage this discussion will certainly continue even in paediatric urology (Caione 2010).

Thursday Thursday, June 9th 2011

Robot assisted Laparoscopic Pyeloplasty Harrie Beerlage Department of Urology Jeroen Bosch Hospital Hertogenbosch, The Netherlands Since the first report on robot assisted laparoscopic pyeloplasty in 2002 over 80 publications on this subject have been published. Most are case reports or decriptions of technical raffinements but also a number of trials have been reported.

Most urologic surgeons use a transperitoneal 4 port approach : a camera port, two robotica ports and one assisstant port. Usually a classical Anderson Heynes dismembered pyeloplasty is performed, duplicating the succesfull open approach. A retroperitoneal approach is also feasible, again with a 4 port configuration. More recently single port robotic pyeloplasty was reported and in the laboratory environment even a NOTES robotic pyeloplasty was performed.

In spite of difficult anatomy in horseshoe kidneys the plasty can be performed as well. In case of stones it is proven feasible and safe to remove the stones in the same procedure.

Most urologic surgeons use double J stenting of the anastomosis, however as in the pediatrie urology some people advocate stentless pyeloplasty. In a retrospective study in 52 patients (35 with and 17 without a stent) no differences in final outcome were found between the groups although 2/17 needed secondary postoperative stenting.

The laparoscopie pyeloplasty has replaced the open procedure as the gold standard for ureteropelvic junction stenosis. In a retrospective of 172 patients the robotic approach (98) was compared with the conventional laparoscopic (74). No differences were found with respect to operating time, complications and longtime outcome on diuretic scintirenography.

In another study prospectively comparing trans and retroperitoneal roboticic pyeloplasty also no differences were found with respect to objective success of the procedure.

In conclusion : robotic pyeloplasty is feasible and with results comparable to the gold standard being laparoscopic pyeloplasty. There seems to be no difference between trans and retoperitoneal approach. Stentless pyeloplasty is an option and stones can be removed in the same procedure.

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Thursday Thursday, June 9th 2011

Small-incision access Retroperitoneoscopic Technique (SMART) Jens Rassweiler, Ali Serdar GĂśzen, Giovannalberto Pini, Michael Schulze Head of Department of Urology SLK Kliniken Heilbronn University of Heidelberg, Germany In recent years Urology has been marked by a progressive research of minimal invasive approaches to reduce morbidity. Laparo-endoscopic single-site surgery (LESS) has occurred, mainly driven by the effort to reduce trauma and improve cosmetics. Although this approach progressively reduced invasiveness and postoperative scar evidence, the complexity of the procedure is increased. LESS proved not easy to be performed, additionnaly associated with a lack of triangulation and the need to manage instruments in a parallel fashion, resulting to difficulties in dissection and manipulation of tissues particularly in absence of adequate tools. Furthermore, until now the cosmetic superiority has not been proven objectively.

We are performing since April 2010 in our clinic small-incision access retroperitoneoscopic technique (SMART) proceduresin our clinic. Briefly; we are creating the retroperitoneal space with a home-made 6-mm balloontrocar. One 6-mm and two 3,5-mm trocars are used for the 5-mm 30° telescope and for both 3-mm working instruments in order to reduce the invasiveness of laparoscopy and preserving also the triangulation and thereby maintaining the effectiveness and advantages of traditional laparoscopy.

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Abstracts Thursday June 9th 2011

We have analysed in an ongoing study prospectively peri- and post-operative data of our SMART series with special attention on scar assessment and postoperative pain. The cosmetic results after the operation were evaluated in an objective way based on a standardized assessment score system - the Patient and Observer Scar Assessment Scale â&#x20AC;&#x201C; (POSAS). As a conclusion: SMART is feasible and effective and providing clearly better cosmetic results compared to standard retroperitoneoscopy.

Thursday Thursday, June 9th 2011

Upper Tract Laparoscopy Nightmares Alan McNeill Consultant Urological Surgeon and Honorary Senior Lecturer Department of Urology Lothian University Hospitals Edinburgh, Scotland The objective of this presentation will be to demonstrate how prior preparation may help avoid any nightmares during upper tract laparoscopy, and provide some tips and tricks for managing problems if they do arise.

As a surgeonâ&#x20AC;&#x2122;s experience of upper tract laparoscopy grows then his indications for a laparoscopic approach will increase, as will the technical challenge of the surgery. Consequently the technical expertise of the surgeon is challenged by these more difficult cases and the potential for unexpected complications increases. We will discuss how to anticipate and manage the difficulties associated with: I) Laparoscopy for large, higher stage RCC II) Cytoreductive laparoscopic radical nephrectomy III) Laparoscopic nephrectomy following infection â&#x20AC;&#x201C; emphysematous pyelonephritis, XGP IV) Managing desmoplastic response associated with upper tract TCC Unexpected haemorrhage is one of the most common causes for emergency conversion to open surgery. This may be associated with malfunction of haemostatic equipment such as staplers and clips, which is always a risk when these are being used (or misued) in laparoscopic surgery. We will discuss how to anticipate, avoid and manage unexpected bleeding.

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Thursday Thursday, June 9th 2011

Nightmares of Upper Urinary Tract Robotic Surgery Giorgio Guazzoni Professor and Chairman Department of Urology UniversitĂ Vita e Salute â&#x20AC;&#x153;Ville Turroâ&#x20AC;? San Raffaele Hospital Milan, Italy The worldwide spread of robotic surgical machines in the last eight years, such as the Da Vinci system (Intuitive Surgical, Inc, Sunnyvale, CA, USA), has changed the way urologists approach laparoscopic procedures.

The seven degrees of freedom and three-dimensional vision are well known advantages of the Da Vinci System.

More and more centres prefer to use robotic surgery over conventional laparoscopic surgery as technically difficult procedures are made easier. Pure laparoscopic experience is undoubtedly required and good training is needed especially for those assisting at the table. Moreover, unlike laparoscopic surgery, table-side surgical assistance plays an important role in establishing consistency during complex procedures.

Of course radical prostatectomy is the most common urological surgery using robotic technology at the present time. However, in the last few years robotics in urology is being routinely offered in institutions for upper urinary tract surgical procedures including the most common indications such as pyeloplasty and partial nephrectomy.

The extended indications for renal tumors less than 7 cm and the spreading use of minimally invasive surgery has increased the number of laparoscopic partial nephrectomies. Different authors have reported the higher risk of complications during laparoscopic partial nephrectomy compared to open surgery. Even if robot assisted partial nephrectomy could be easier than pure laparoscopic surgery, it should still be considered as a difficult procedure.

The pedicle isolation represents one of the trickiest stages and good isolation is important to perform the procedure. An important role is related to the renorraphy. A good haemostasis and the absence of urinary fistula are both linked to excellent suturing skills.

In conclusion, upper urinary tract robotic assisted surgery is an extremely difficult type of surgery that requires tremendous skill and training.

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Abstracts Thursday June 9th 2011

Ureteropelvic junction obstruction is not a common pathology and as a consequence complications occur due to the lack of knowledge of the procedure. An example of an alternative approach to pelvic junction is transmesocolic access. However, this could be dangerous and have some limitations especially in obese patients due to the presence of thicker mesentery. A crossing vessel is sometimes the cause of ureteropelvic junction obstruction and therefore requires extremely refined surgical skills to complete such an operation.

Thursday Thursday, June 9th 2011

Nightmares in Laparoendoscopic single site surgery (LESS) Jihad H. Kaouk Zegarac-Pollock Professor of Surgery Institute Vice Chair for Surgical Innovations Director, Center for Laparoscopic and Robotic Surgery Glickman Urological and Kidney Institute Cleveland Clinic Cleveland, USA LESS was conceptualized and developed over the last 4 years in an attempt to further minimize the invasiveness of conventional laparoscopy. Despite unsolved challenges, LESS can be regarded as a new global trend in minimally invasive urologic surgery and it has significantly evolved, becoming a widely applicable technique.

A broad range of both extirpative and reconstructive procedures can be effectively done by LESS techniques.

Overall, a non-inferiority of LESS as compared to standard laparoscopy has been demonstrated with a trend towards a benefit in terms of patient discomfort and cosmesis. Any new surgical technique requires a stringent assessment of its risks. Despite its promising outcomes so far, LESS requires an experienced laparoscopic surgeon to ensure a safe and successful procedure. When starting LESS, patient-selection criteria are expected to be stricter than with conventional laparoscopy. Sensitivity to the potential for complications is critical, and the threshold for conversion must be appropriately low. Disease features (ie, locally advanced disease requires more extensive dissection; abnormal anatomy requires extensive suturing) and patients features (ie, body habitus, BMI, comorbidity score, previous surgery or RT, personal preferences for better cosmetic outcome) are to be considered.

In a multi-institutional study looking at complications and rates of conversion from LESS to conventional laparoscopy at the time of upper tract urologic procedures, 125 patients were analyzed and conversion to conventional laparoscopy was necessary in 5.6% and complications occurred in 15.2% of patients undergoing LESS surgery.

In a more recent multi-institutional worldwide experience, 1076 cases of LESS were included in the analysis.

Overall conversion rate was 20.8%, being 15.8%, 4% and 1% to â&#x20AC;&#x153;reduced portâ&#x20AC;? laparoscopy, conventional laparoscopy/robotic and open surgery, respectively. Intraoperative complication rate was 3.3% with need for conversion to open in 3 cases and laparoscopy in 5 cases. Postoperative complications were encountered in 9.5% of cases, mostly being low grade according to Dindo-Clavien. Based on currently available evidence, complications with LESS seem to be of similar nature and to occur with similar frequency to those experienced during standard laparoscopy. Undeniably, a solid laparoscopic surgical background is critical for a successful LESS and complications are unlikely only if stringent patient selection criteria are applied.

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Notes

Notes

Friday

Friday, June 10th 2011

4:00 4:40 pm Moderators

Peter Rimington Peter Wiklund Joachim Thüroff 4:40 5:20 pm Moderators

Roland Van Velthoven Vipul Patel Manfred Wirth 5:20 6:00 pm Moderators

Debates Walter Artibani, Konstantinos Konstantinidis Cystectomy Standard Laparoscopy vs. Robot Assisted Laparoscopy vs. Open Speaker Lap Speaker Robot Speaker Open

Joachim Thüroff, Tullio Sulser Modifications of Radical Prostatectomy Evidence based data or surgeon’s wisdom Speaker Lap Speaker Robot Speaker Open

Thierry Pièchaud Jens Rassweiler Michael Truß

Ingolf Türk, Panagiotis Kallidonis General management of complications during Radical Prostatectomy Vascular injuries Rectal injury Anastomotic leakage

6:00 pm

Adjournment

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Friday

Friday, June 10th 2011

Laparoscopic Cystectomy Peter Rimington Director of Urology Eastbourne District General Hospital Eastbourne, UK

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Friday

Friday, June 10th 2011

Robot Assisted Laparoscopic Cystectomy Peter Wiklund

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Abstracts Friday June 10th 2011

Professor and Chairman Dept. of Molecular Medicine and Surgery, Section of Urology, Karolinska Institut Stockholm, Sweden

Friday

Friday, June 10th 2011

Gold Standard: Open Radical Cystectomy Joachim Thüroff, Wolfgang Jäger Professor and Chairman Department of Urology University of Mainz Mainz, Germany Open radical cystoprostatectomy is the gold standard for radical surgical treatment of bladder cancer.

Laparoscopic and robotic-assisted laparoscopic surgical techniques of radical cystoprostatectomy aim at copying the principles of this reference standard. Hence, indications and surgical strategies of radical cystectomy are reviewed. Indications and limitations of different surgical strategies (“increasing radicality”or“reducing radicality”) are discussed for radical cystectomy in males and females and for pelvic and retroperitoneal lymph node dissection.

Decreasing radicality Males: In males, indications, surgical technique and results of nerve-sparing radical cystoprostatectomy and prostate-sparing radical cystectomy are presented and discussed.

Females: In females, indications, surgical technique and results of urethral-sparing cystectomy, nerve-sparing, vaginal-sparing and uterus-sparing techniques are presented and discussed.

Lymph node dissection (LND): Reduction of the extent of lymph node dissection (limited vs. extended pelvic lymph node dissection [PLND], retroperitoneal lymph node dissection [RPLND]) are discussed in respect to nerve-sparing techniques and probability of skip lesions.

Increasing radicality Males: Indications, surgical techniques and results of primary urethrectomy are presented and discussed.

Female: Indications, surgical techniques and results of primary urethrectomy, hysterectomy and anterior/complete vaginal resection are presented and discussed.

Lymph node dissection: Extent, templates and numbers of lymph nodes removed in pelvic ± retroperitoneal lymph node dissection are presented and discussed in regard to probability of skip lesions and results (CSS).

Comparison: Where available, comparative studies between open, laparoscopic and robotic-assisted laparoscopic radical cystectomy are discussed in regard to surgical strategies of reducing or increasing radicality, advantages/limitations and possible choices for urinary diversion.

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Friday

Friday, June 10th 2011

Modifications of Laparoscopic Radical Prostatectomy Roland Van Velthoven

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Abstracts Friday June 10th 2011

Chairman Department of Urology Service InterHospitalier d'Urologie Institut Jules Bordet Hospital Saint Pierre Brussels, Belgium

Friday

Friday, June 10th 2011

Modifications of Robot Assisted Laparoscopic Radical Prostatectomy Vipul Patel Medical Director of Urologic Oncology, Florida Hospital Medical Director of Global Robotics Institute Associate Prof of Urology University of Central Florida Florida, USA

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Friday

Friday, June 10th 2011

Modifications of Open Radical Prostatectomy Manfred Wirth

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Abstracts Friday June 10th 2011

Professor and Chairman Department of Urology Universitätsklinikum “Carl Gustav Carus” der Technischen Universität Dresden Dresden, Germany

Friday

Friday, June 10th 2011

General management of complications during Radical Prostatectomy: Vascular Injuries Thierry Pièchaud Center of Urologic Laparoscopy Clinique Saint Augustin Bordeaux, France Chairman of Urologic Courses IRCAD-EITS, Strasbourg, France

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Friday

Friday, June 10th 2011

General management of complications during Radical Prostatectomy: Rectal Injury Jens Rassweiler Head of Department of Urology SLK Kliniken Heilbronn University of Heidelberg, Germany Background: Laparoscopic radical prostatectomy (LRP) represents an established treatment modality of localized prostate cancer.

Objective: To report standardized complication rates of LRP, to evaluate the development of complication rates over time and to show changes within the learning curves of laparoscopic surgeons.

Design, setting and participants: Standardized analysis of 2200 consecutive patients who underwent LRP between 1999 and 2008 at a single institution.

Intervention: LRP was performed using a transperitoneal (N=871) or extraperitoneal (N=1329) retrograde Heilbronn-technique. Five surgeons operated on 96% of patients.

Measurements: Complications were classified according to the modified Clavien-system. Total complication rates and changes over time were analysed. Three generations of surgeons were defined for evaluation of learning curves.

Results and limitations: Minor complications occurred in 21.7% (6.8% Clavien 1, 14.9% Clavien 2), anaemia requiring transfusion (10.4%) dominated. Early re-interventions were necessary in 6.7% (3.6% Clavien 3a, 1.5% Clavien 3b, 1.5% Clavien 4a, 0.1% Clavien 4b). Late Clavien 3b complications occurred in 4.7%, most of them were anastomotic strictures. Mortality was 0.1% (Clavien 5). There was a significant decrease in overall complication rates over time resulting predominantly from decreasing Clavien 1-2 events. Learning curves of third-generation surgeons plateaued earlier compared to the first generation (250 vs 700 cases). Limitation is that data concerning comorbidity were not included.

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Abstracts Friday June 10th 2011

Conclusions: LRP is a safe procedure characterized by an acceptable profile of complications. Specifically, few major complications are reported. According to the complication rates, the learning curve of third generation surgeons is significantly shorter compared to first and second generation.

Friday

Friday, June 10th 2011

General management of complications during Radical Prostatectomy: Anastomotic Leakage Michael Truß Professor and Chairman Department of Urology Klinikum Dortmund Dortmund, Germany There is no unanimously accepted method of categorisation of anastomotic leakage in the literature. Even though there are no strictly defined criteria, we have attempted a categorisation facilitating postoperative management of these patients. This classification is based on our scheme of catheter removal on the 5th postoperative day.

We routinely perform a cystography prior to catheter removal. The final decision of catheter removal is certainly a clinical decision and should not be based strictly upon the recommended classification.

—Minor leak requiring 3 extra days of catheterisation —Minor leak requiring an extra week of catheterisation.

—Major leak requiring insertion of mono J catheters and minimum of two weeks catheterisation.

—Major leak after dislocation of the catheter.

—Major leak requiring reintervention.

If the urine output through the urethral catheter is less than the output of the drain for more than 48 hours, then reintervention and reformation of the anastomosis should be considered. The reintervention is performed endoscopically (laparoscopically). Normal cystographies as well as the different cystographies depicting the various types of anastomotic leakages are demonstrated.

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Notes